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1、Revascularization in Complex Patient Subsets: A Report from the ACC.09 and i2 Summit 2009,Modified from Robert A. Harringtons ACC presentation,葛均波 复旦大学中山医院 上海市心血管病研究所,Revascularization in Complex Patient Subsets,The very elderly (C. Grines) Complex CAD and diabetes (V. Fuster) Chronic kidney disease
2、 (N. Lepor) Poor LV function (J. Bax) Vascular complications and women (B. Ahmed),Revascularization In The Very Elderly,Cindy L. Grines, M.D., F.A.C.C. William Beaumont Hospital Royal Oak, Michigan, U.S.A.,In-Hospital Complications After PCI: Effect of Age,Bachelor, JACC 2000;36:723,Complications* A
3、fter Elective PCI in Octogenarians,Death,MI Q-wave,Stroke,Death/MI/ CVA,Renal failure,Vascular complications,Bachelor. JACC 2000;36:723,* p .001 for all complications,*,*,*,*,*,*,Safety Concerns in ACS Care: The Elderly Bleed More,Yang et al J Am Coll Cardiol 2005;46:1490-5,0,5,10,15,20,55,55-64,65-
4、74,75,Age group (years),Blood Transfusion (%),Acute Coronary Syndrome Registries,Elderly patients Vague symptoms More co-morbidities Less likely to receive medical treatments of proven benefit Less likely to receive cath or revascularization Worse outcomes,PRAIS-UK, Age and Aging 2005;34:61-66 CRUSA
5、DE, JAMA 2004;292:2096-104 GRACE, Am Heart J 2005;149:67-73,TACTICS-TIMI 18: Elderly ACS Patients Benefit the Most From Early Invasive Strategy,Ann Intern Med 2004;141:186-195,AMI in the Elderly,Advanced age strongest determinant of early and late mortality 80% of all deaths are in patients 60 years
6、 old risk of intracranial bleeding Minority receive lytic therapy (10% of patients 65 years old),DeGeare. AJC 2000;86:30,PCI restored TIMI 3 flow in 92% of young, 85% of elderly (p=.001),Outcome of PAMI Patients Based on Age,Senior PAMI: 30-Day Outcome Based on Age Stratified Randomization,PCI Lytic
7、,38% p=.17,36% p=.18,55% p=.0093,p=.72,p=.57,p=.96,Event rate,3,6,9,12,15,18,21,24,Diabetes + CVD,0.00,0.05,0.10,0.15,0.20,Months,No diabetes + CVD,Diabetes + no CVD,No diabetes + no CVD,3) Risk of Cardiovascular Mortality: OASIS Registry (n = 8,013),Malmberg K, et al. Circulation. 2000;102:1014-101
8、9.,Mortality in Patients Assigned to CABG or PCI According to Diabetes Status,10 Trials, 7812 pts, Angiopl 6 Trials 373: March 20th,2) BARI-2D: Evaluating Treatment Options for CAD and DM in Type 2 DM,Inclusion Criteria Type 2 DM Stable CAD,Exclusion Criteria Mandatory CABG Unstable CAD CAD extent L
9、V function,BARI-2 Committee: K. Detre, R. Frye, T. Orchard, D. Kelley, R. Nesto, B. Sobel, S. Genuth, B. Chaitman,Revascularization of Choice & Medical Rx,Revascularization of Choice & Medical Rx,Medical Rx,Medical Rx,2 x 2 Factorial Design (n = 2300),CATH,Insulin Providing,Insulin Sensitizing,CABG
10、(n = 897) DES (n = 903),All-cause MI Stroke Death/MI/Stroke Revasc MACCE Interv ! CTS ! death,%,Main Results at 1-Year,2) SYNTAX Trial (TAXUS DES),3.5,4.3,3.2,4.8,2.2,0.6,7.7,7.6,P = 0.37,P = 0.11,P = 0.003,P = 0.98,P 0.0001,P = 0.0015,5.9,13.7,12.1,17.8,Serruys P et al. NEJM 2009;360:961 - SYNTAX h
11、igh Score Favors CABG,2) SYNTAX Trial Conclusions: (victory for both camps) Surgical Viewpoint: PCI was inferior to CABG and failed to meet its primary endpoint,PCI Viewpoint: PCI was equal to CABG in hard endpoints of death & MI (even in LM) and Any pt will trade re-PCI (+8%) to CVA,Aggressive back
12、ground therapy for CAD and diabetes,Contemporary PCI with DES n = 1,000,Patients: DM and multivesel CAD eligible for PCI or CABG,Contemporary CABG with or without CPB n = 1,000,Randomized 1:1,3) FREEDOM ( NHLBI ),3) FREEDOM Recruitment: 1532 patients,2005,2006,2007,2008,1408,1503,1298,1532,as of 1/2
13、8/09,2009,US: Mount Sinai Medical Center Canada Vancouver Hosp and Health Sciences Center Canada Montreal Heart Institute South America InCor Heart Institute South America Institute Dante Pazzanese,CABG is superior to PCI with regards to the need for repeat revascularization; DES-PCI is closing the
14、gap Well-powered trials of at least 3-years duration are required before definitive conclusions on the cluster of death/MI/Stroke can be drawn The SYNTAX Score can help guide therapy ; more complex disease benefits from CABG while others achieve equal results with PCI Major emphasis should be put on
15、 intensive CV risk factor management. It is critical that both arms achieve optimal control of risk factors,TAKE HOME MESSAGE,Coronary Artery Revascularization in Patients with Chronic Kidney Disease.,Norman E. Lepor MD FACC Cedars-Sinai Heart Institute Associate Clinical Professor of Medicine Geffe
16、n School of Medicine-UCLA Westside Medical Associates of Los Angeles,CKD and Revascularization,PCI higher risk owing to increased incidence of acute renal injury, restenosis and mortality CAB higher risk for all cause mortality Longer postoperative bleeding times Higher postoperative bleeding rates
17、and transfusion requirements Increased length of hospital stays,Kidney Int. 1999;55:1057-1062.,CONTRAST-INDUCED NEPHROPATHY IN-HOSPITAL MORTALITY,Profound increase in in-hospital mortality in patients developing acute renal failure (ARF), particularly in diabetic patients,% IN-HOSPITAL DEATH,P .0000
18、001,No ARF,ARF,Dialysis,McCullough, et al. Am J Med. 1997:103375.,1.1%,7.1%,35.7%,Incidence of Adverse Outcomes 6 Months With STEMI Reperfusion-GRACE Registry,J Am Coll Cardiol Intv 2009;2:26-33,Incidence of Hospital Stroke and Major Bleeding Stratified by Renal Function in GRACE Registry,J Am Coll
19、Cardiol Intv 2009;2:26-33,Survival Post PCI in EVENT Registry,J Am Coll Cardiol Intv2009;2:37-45,Survival After Revascularization in CKD Alberta Provincial Project for Outcomes in CHD (APPROACH),Circulation 2004;110:1890-95,Nondialysis CKD,Dialysis-CKD,Survival Post CABG in ESRD,J Am Coll Cardiol 20
20、04;44:1343-1353,Algorithm For Revascularization in CKD A Nephrologists Perspective,Clin J Am Soc Nephrol 2006;1:209-220,Conclusion,The CKD patient represents a challenging patient population to treat with revascularization Has unique physiology predisposing both to the development of CAD and complic
21、ations of revascularization therapies No recent randomized trial experience to guide selection of therapy Data seems to support the use of PCI (DES BMS) in patients with mild to moderate CKD Surgical revascularization may be best in those with ESRD,Revascularization in poor LV function,Jeroen J Bax
22、Dept Cardiology Leiden University Medical Center The Netherlands ACC 2009, Orlando Grants: GE healthcare, BMS medical imaging, Edwards Lifesciences, Biotronik, St Jude Medical, Boston Scientific, Medtronic,Ischemic LV Dysfunction,Clinical goal: -identify patients with viable tissue -with potential t
23、o recover function -to justify enhanced surgical risk,How to assess viability?,Metabolism (glucose, FFAs): FDG, BMIPP Intact cellmembrane: Tl-201 Intact mitochondria: Tc-99m Intact perfusion: Tl-201, Tc-99m, MCE Contractile reserve: stress echo / MRI,Conclusions,Revascularization in low EF has enhan
24、ced risk Assessment of viability is important But also: Scar extent LV size and function Mitral regurgitation,Significantly Improved Vascular Complications Among Women Undergoing PCI: From the Northern New England PCI Registry,Bina Ahmed*, Winthrop D. Piper, David Malenka, Peter VerLee, John Robb, M
25、erle Kellet, Thomas Ryan, Michael Herne, William Phillips and Harold L. Dauerman* *University of Vermont College of Medicine,Vascular Complications Decreasing After PCI: Is This True for Both Women and Men?,Dartmouth- Hitchcock Medical Center,Fletcher Allen Health Care,Eastern Maine Medical Center,C
26、atholic Medical Center,Maine Medical Center,Portsmouth Regional Hospital- Affiliates York Hospital and Wentworth Douglass Hospital,Concord Hospital,Central Maine Medical Center,Northern New England Cardiovascular Disease Study Group,Methods,Vascular Complications Among Women are Linearly Related to
27、Age,Vascular Complications in Women Have Decreased Dramatically,Revascularization in Complex Patient Subsets,The very elderly (C. Grines) Complex CAD and diabetes (V. Fuster) Chronic kidney disease (N. Lepor) Poor LV function (J. Bax) Vascular complications and women (B. Ahmed),Outcomes Following Co
28、ronary Stenting in a Linked NCDR and CMS Database: A National Study of Long-Term, Real-World Outcomes of Bare-Metal and Drug-Eluting Stents,650 sites; 262,700 patients 65 years DES 217,675; BMS 45,025. Unadjusted Follow up from Medicare claims data at 3 years,We thought so: patients treated with DES
29、 do better.,-Slide courtesy of DR Holmes,谢谢,Myocardial Infarction and Ischemia,NSTE ACS Integrating new and old therapies Thienopyridines and GP IIb/IIIa inhibition Strategy trials ABOARD Immediate vs. delayed angiography EARLY ACS Routine early vs. delayed provisional GP IIb/IIIa inhibition,-Slide courtesy of LK Newby,Myocardial Infarction and Ischemia,New concepts in treatment with proven therapies Statin preloading for PCI ARMYDA-RECAPTURE NAPLES II Plieotropic effects (? Inflammation) The polypill,-Slide courtesy of LK Newby,